Ingenious: Carl Erik Fisher

The meditative psychiatrist.

The reactions to Carl Fisher’s Nautilus essay, “Against Willpower,” ranged from the appreciative to the sorely defensive. Why…By Michael Segal

The reactions to Carl Fisher’s Nautilus essay, “Against Willpower,” ranged from the appreciative to the sorely defensive. Why should we be asked to give up the idea of willpower? Aren’t we just giving ourselves and others permission to fail? Is this a political idea in disguise?

That we’re so invested in the idea shouldn’t surprise us, Fisher explains. The successful like the idea that their willpower has enabled them; those who are struggling with some aspect of their lives appreciate the achievable goal it presents.

Fisher noticed the patients in his psychotherapy practice referring to it often (he specializes in addiction), conceptualizing it as a unitary, comprehensive resource that can be developed like a muscle, or exhausted. As he studied willpower more deeply, though, he realized that modern research has shown this to be a myth—and “willpower” a label on a collection of disparate concepts that don’t belong together.

As someone who has studied and practiced family therapy for 37 years, I am repeatedly struck by a secret’s impact on a family. With the best intentions, parents often strive to protect a child from a shameful or painful...READ MORE

Should we go cold turkey on the word? Not necessarily, Fisher says. Instead, he challenges us to notice when we use it, and to be critical about what we actually take it to mean. “I’ll take an analogy from meditation,” he explains. “The objective of most forms of meditation is not to scrub your mind clean of any and all thoughts, it’s to fully accept and recognize when some thought is entering.”

In speaking to Fisher about topics from addiction to neuroscience, this meditative attitude shines through. That, too, is not a surprise—an assistant professor of clinical psychiatry at Columbia University, and a practicing clinician, Fisher also has a deep background in meditation. He spent a year in Seoul studying Zen meditation and neuroscience, uses meditation in his practice, and meditates himself.

Our conversation made something else clear, too: In emphasizing awareness and a kind of “data-taking” attitude toward the world, meditation is deeply aligned with the principles and practice of science itself. Maybe more scientists should try meditating—a topic for our next conversation.

Fisher sat down with us in our Manhattan office this February.

To see the video interview, click the “play” button at the top of this article.

I got curious about “willpower” because I kept on seeing it in my own clinical material. People who had serious substance abuse problems, or who were more on the borderline between what you would call traditional addiction and “regular” or “moderate” use of substances, kept on coming to me and saying to me, “I’m struggling with willpower”—and I got curious about the concept.

I think that in popular culture—and even in academia—there’s this pervasive idea that there’s some unitary comprehensive function called willpower that applies across multiple contexts and in many cases, it’s conceived of like a resource, like a thing that you use up over time and that you can develop like a muscle. But, it’s just wrong; it’s a myth. There have been several converging lines of research that show that that overarching definition of willpower is not true.

So it deserves skepticism and reconfiguring because there are harms and it causes problems. It misleads people—but there are even negative effects of believing in the willpower model itself so I thought it would be useful to explore that concept and translate it in a way that would tell the whole story of how it came about.

Why are we so attached to the idea of willpower?

People who are successful, or people who feel like they are able to employ willpower, that they’re gifted with a greater proportion of willpower—they feel like it says something good about them. This is where some of the moral ideas and the value-laden ideas of willpower come in: There is something better about having willpower and they don’t want to give up the concept that they might be better in that way.

I also think that even for people who struggle with it, it seems like a safe and understandable mechanism for understanding how we achieve our goals. It’s common for everyone to struggle with trying to direct yourself toward a long-term goal. Most people struggle with that in some aspect, whether it’s money, work, weight, exercise—or substances or something that causes more direct harm. So people are struggling to find a way to make sense of it and I think it can be more confusing, in some respects, to discard one organizing simple concept and try to break it down into its constituent parts.

But, that overarching concept doesn’t work, and there are better options for achieving those long-term goals, things that have actually been proven to be more successful.

How should we think about the virtues of sustained willpower and reaching long-term goals?

We have a lot of different ways of talking about willpower, and even an individual may have a number of different concepts, which are not consistent with each other, when they say willpower. Sometimes it might refer to this prospective long-term attempt to achieve a goal; sometimes it might deal more with the immediate struggle with impulses and cravings.

It’s important to think about the long-term process of self-control, but because there’s so much baggage attached to willpower, and because even in the academic literature it’s been discussed in so many different ways, I think it’s better just to be specific about what we’re talking about. If we’re talking about bringing our long-term goals into alignment with what we want right now, let’s talk about that as a cognitive process and then think about all the different strategies that people might use to get from point A to point B.

But you bring up the idea of prospective strategies and I think that’s a good indication of better alternatives to willpower. The immediate suppression of top-down impulses and cravings and urges is not helpful; it may be harmful. Certainly, believing that that’s a useful strategy or that it relies on some sort of unitary concept is harmful; it leads to worse outcomes, whether it’s a very narrow psychological test when someone is trying to inhibit a response or a sort of broader life goal.

The things that seem to give people success in achieving those goals have less to do with what we traditionally associate with willpower and more to do with that sort of prospective intention setting. Planning ahead and avoiding the temptation in the first place. Setting up a structure and a schedule so that you are better able to go through with the original intention. Even the act of setting an intention itself and making a plan seems to have some sort of subconscious effect on people’s ability to resist future temptations.

So there’s something to that; but if we lump all that together—the immediate suppression of urges along with all of those other disparate strategies that surely employ different cognitive mechanisms—then it just gets too broad, too vague, and we lose track of what we’re talking about.

How did you end up studying meditation in South Korea for a year?

When I was an undergrad, I was at The University of North Carolina at Chapel Hill, which is a fantastic institution, I really loved it; but like a lot of public universities, they wanted to raise their stature and get more people who won big fellowships and trophies. So anyone with above a certain GPA was herded into an auditorium and they got this hard sell, “You should apply for the Rhodes, the Marshall, the Mitchell, all the rest.”

Everyone went up there and they gave their speeches—wonderful, smart, committed people. And then this one guy came up and talked about how he lived in Mongolia and used his fellowship money to buy a motorcycle and he got into a knife fight in some yurt, and I thought, this is the guy for me. So I went up to him and heard about the fellowship, and I wound up applying for this fellowship where they give it to you and then after the fact, figure out where you’re going.

I went off to South Korea because I was interested in continuing to do some scientific research, but really, engaging in a different culture and learning directly from the source how to meditate; because up to that point, like a lot of people in the States, my understanding was purely intellectual. I like to read books about mindfulness and about the philosophical or metaphysical ideas about Buddhism, but I had this sense that I just needed to learn the skill. Some of it was just the face-to-face transmission of some sort of skill to practice and so I went over there.

I did do some research. And I sang in an opera company, which was great. I was the token white guy who they brought on stage for The Phantom of the Opera encores. But the real meat of the experience I think, that really stuck with me was that sort of training and actually doing meditation retreats and sitting down with a teacher and saying, “My mind feels crazy. What do I do with that?” That was invaluable; and even though it took me several years before I got back to clinical applications of mindfulness, it seeded that idea that mindfulness and more rigorous psychiatry and neuroscience could be blended together.

Why has there been such a surge in interest in meditation?

I’m extremely biased because I’m a meditation practitioner myself and I also use it in my clinical practice; but, I think that it’s fairly well established at this point that it works in some contexts. Meditation has definite benefits in a clinical context when you’re dealing with mental disorders or other issues, but also in a general sense.

I don’t want to oversell it because there are plenty of people who do oversell the concept of mindfulness, but it does work for some applications, say for mindfulness-based cognitive therapy for depression. It seems to have a longer rate of remission. People just tend to stay well longer. In general psychology, people are better able to pick up on their interoceptive … their body-based cues have more of an attitude of acceptance when a negative thought or a negative experience comes up. So, it has real benefits.

I think that when it first came over to the States, it was translated by some brilliant and excellent communicators, but it was still cloaked in spirituality. As a primarily Judeo-Christian nation, a lot of the population had some resistance to that. It’s only recently that it’s been refashioned into a more secular context and now we have purely secular drop-in meditation centers, and apps, and a wide range of applications in clinical or other contexts.

Many people have brought up the issue that now there’s some context where it might get overly-secularized. Simply treating mindfulness by itself as one meditation strategy, divorced from all the rest of the contemplative tradition it’s gotten along with, might not get people to where they’re looking to go. So we’re struggling with that balance of what goes along with mindfulness or, is it just mindfulness that goes into meditation practices and contemplative practices?

But, I think people like the idea of a tool. They like the idea that there’s an actual practice you could do that helps the way you think. Most of us spend at least four or five minutes a day brushing our teeth, so if we’re going do that for our teeth, we might as well do it for our minds as well.

What do you find challenging about your own meditation practice?

What I’ve found about meditation is there’s a balance of right effort. So in the Buddha’s eightfold path, there a bunch of different things that are right to do. It doesn’t mean do them perfectly or 100 percent. Right livelihood, right speech. One of them is right effort.

I’ve always struggled with effort. I’ve always wondered about what is the right amount of effort, even on the meditation cushion. I’m sitting there. I have an object of concentration. Whether it’s some sort of basic compassion intention like, may all beings be happy; or whether it’s just simply staying with the breath, and following my awareness. What’s the right amount of effort? Do I hold onto it tightly and really try to make sure I don’t miss a second? Or do I relax and be loose about it and let my mind go where it will? There’s a whole spectrum of responses and you’ll go across the entire spectrum over the course of a meditation session.

I try to apply that sort of middle path to a daily sitting practice for myself and my patients. I try to sit everyday. I usually do. There was a time when I didn’t. I would beat myself up and say I was a bad meditator and I’ll always be suffering and my life will be shit. And I’ve let go of that a little bit. It helps. It’s good.

And especially in New York, I think a lot of people, especially people who are successful or intellectual or are strivers, or are trying to achieve some big goal. Their problem is generally not being too easy on themselves. Most people in the city are too hard on themselves! So, not that I am trying to apply my own experience to everybody, but I find a lot of commonality and a lot of common ground with my patients along those lines.

Tell me about the Zen wars.

People have different practices and there’s always been a dynamic around some judgment in different ways of accessing these types of practices. There were plenty of battles between different types of Zen. It got vicious in Japan for quite a while. “This school doesn’t know anything.” “This school is leading their students on a blind path.” And then now in the States where multiple lineages from different cultures have been transmitted, there’s a lot of battling or judgment or accusations being thrown about: Tibetan versus Zen, or whatever else. It’s just a form of tribalism, you know; I don’t think it’s anything different.

It was life and death for people. If Zen was intended to cut through to the most important questions of life and death—and the way to live life—and you thought the other school was doing it totally wrong, then it was life and death. They were wasting their lives and it needed to be corrected—and there have been various correctives in the history of Buddhism.

When Zen was transmitted to Japan, there were different schools and the founder of the school that I tried to study in—and I’m not a teacher so I don’t mean to give a lecture about Buddhism but, my understanding is that Dōgen, the founder of the Sōtō school, saw a lot of problems with over-intellectualization. So there were a lot of negations in his teaching. There was a lot of talking about what Zen isn’t; or what experience isn’t; or what consciousness isn’t. And the way it has sometimes been received is that it can be very pessimistic, or nihilistic, when some of that is just a cultural relic. It will evolve in a different way in different circumstances.

I think it’s great that there’s friction; it can bring to light some of the cultural conditioning. One of the elements of friction in the American Buddhist community right now is around privilege. Most American Buddhists are white; they’re mostly a higher socioeconomic status, and consequently many of the teachers are older and more privileged. How does that kind of Buddhism engage socially and acknowledge inequality and do something about some of the social issues we’ve inherited? To my mind, that’s where most of the friction is today and not about a metaphysical question about the right way to practice. That’s good! That’s where we need the questioning now.

Is the word “mindfulness” problematic?

I’m not sure that I would replace the word “mindfulness,” but I would agree that it’s acquiring a lot of connotations—and in some cases some negative ideas—that are leading to confusion. People do oppose the idea of mindfulness; sometimes they do it in a snarky way. But some people, I think, fundamentally misunderstand the point of it and say, “Why would I be mindful when I’m cleaning my dishes? That’s boring. I might as well think back on that great film I saw. Or, that great performance I saw. It just seems more enjoyable. Why bother?” The overselling of mindfulness can lead to this idea that we should always be rigidly focused on what’s in front of us and our minds should be totally clear of any sort of input or thought. That’s a total misrepresentation.

Mindfulness doesn’t mean the eradication of thoughts, in any tradition. In any sort of basic, secular, clinical application, it just means paying attention to the present moment. That could mean the thoughts that are coming up, the preoccupations that are coming up; it could mean to use your mind in an intentional way so you’re not so rigidly obsessively scrubbing away at a piece of jam on a plate. So initially, mindfulness had this notion of broad support—who could oppose it? But now that it’s become so popular, it’s acquired certain connotations that people are starting to resist—and maybe with good reason. Maybe we need to clarify what we mean by mindfulness before we slap it on a bunch of posters in every school and every workplace.

How is neuroscience changing our notions of responsibility?

I like to teach this example of a man who had a tumor in mid-life and his behavior totally changed. He, all of a sudden, became very interested in sex, when before he was a very mild-mannered man. He even made some sexual advances toward his daughter—completely out of character. It’s a very clean example. We can look at the tumor inside his head. They took out the tumor, the behavior went away; the tumor regrew, the behavior came back—and so forth and so on.

When you think in a really rigorous way about psychic determinism and the role of the brain in creating behavior, it’s not clear that his example is any different from anybody else. What makes someone a pedophile or struggle with sexual impulses if not their brain? And, if the locus is in their brain, then what makes their responsibility any more or less than someone who has a tumor? A hundred years from now we may be able to talk about brain function in a deterministic way, even if there’s not such a clear obvious organic issue.

So, I don’t have the answer. It tracks back to what version of free will and responsibility you want to acquire. People wonder about the degree to which neuroscience will filter down through the courts into public consciousness about determinism and personal responsibility. I think it’s an open question, but we may have an entirely different conception of responsibility in the decades that come, especially if we see more concrete examples of brain science being used in the courts.

The thing that’s interesting to me about the courts is that we are seeing deep philosophical ideas—like free will and responsibility—being put into forced-choice scenarios where you have to say, “guilty” or “not guilty.” We don’t have all the information; there’s no consensus about what the best model for free will or the best theory of punishment is. But, at a certain time and a certain place, someone has to render a judgment. So, how do we do that? What is our mechanism? What is our process for thinking through those sorts of ethical and philosophical issues when we have to, even understanding that we don’t have all the information and there may not be a right answer.

How is neuroscience informing marketing?

I wrote this article about neuromarketing back when I was in medical school because at that time it was being broadly advertised and several marketing consultancies were saying, “We can do this cool process where we can look into your customers’ heads and figure out how to make them buy things or how to make them change this behavior.” And there was massive blowback. Consumer advocacy groups came out and said that this was Orwellian, this was awful, we need to stop.

My sense of it now is that everyone has gone underground. There’s not a lot of discussion. But large companies like Nielsen have acquired some of these consultancies and they’re still doing the work. It’s hard to know what neuromarketing is nowadays. It’s hard to know how the business-to-business transactions are going but the fundamental product that they’re trying to sell is a backdoor to people’s behavior, some sort of way to shortcut their conscious deliberation and make them do something they don’t intend to do. That’s been around ever since the 1960s.

There was this big controversy over subliminal advertising and some overblown claims about making people buy popcorn just by flashing subliminal messages on a movie screen. It turns out to be a complete fabrication, or at least a real exaggeration about what subliminal messaging can do. But it plays into a fear I think we’ve had since well before the 20th century, that people with special knowledge about psychology or about human behavior can somehow influence you to do something you can’t do. So it works. It’s a convincing pitch to a company, but from what I’ve seen it doesn’t have a lot of effect.

There’s this famous neuromarketing study that was published in The New York Times and it got a lot of flak for being a bad example of inferences made off of neuroimaging data. People were shown images of different political candidates—this was back in the Romney era—and the reason it was so roundly criticized, certainly in blogs and by people who were critical about the use of neuroscience, is because it fell prey to some of the classic errors in thinking about neuroimaging data that would never get accepted by any scientific publication. One clear example is reverse inference.

They showed people photos of Mitt Romney and then there’s activity—I think in the insula, which is active across a huge range of cognitive processes. But then the neuromarketers said, they sort of cherry-picked a particular emotional response and they said, “this has to do with fear.” But we don’t know. Just because a brain area that is commonly engaged in some sort of cognitive process is active, that doesn’t mean that we can do the reverse inference of brain area to cognitive process. For example, some critics said it could be fear; it could be lust. We don’t know. It’s acting in so many different cognitive conditions, there’s no way to make that leap.

I say all this because I’m not scared about the use of neuromarketing today. Not really seeing the inner workings of the business—I don’t know what’s out there, but at least from what’s been out there recently—I think it seems to be trading on a very surface level and unscientific portrayal of neuroimaging data.

Why is psychiatry underserved in the United States?

Well, it’s just a statistical fact that if you calculate the number of people with serious mental disorders, or the general need in the population, we don’t have enough practitioners. That’s true of physicians in general. We have a general physician shortage in the United States that’s felt much more strongly in primary care and family medicine. We certainly have enough specialists in many areas of the country.

Psychiatry in particular—I think it’s fascinating: We have amazing and wonderful candidates and applicants coming in every day, but it carries with it a stigma. It has always been one of the less competitive specialties of medicine. Some of that is very concrete; some of that is just a pipeline problem: How do we get people from point A to point B? How do we get people credentialed and adequately trained to perform the service? And some of that comes from the sense of stigma that psychiatrists are weird, or that it’s an impossible profession, or that it’s too narrow and it doesn’t deal with the root causes of the social problems or the mental problems it encounters.

But, we need more, and if we don’t take more active steps to correct the workforce shortage—one of which might include making sure that we can accept people from other countries and not revoke their visas summarily—then a lot of people, especially in rural areas, especially in parts of the country that already don’t have great health care, will suffer. So it’s an urgent need in the country today.

Is psychiatry becoming more reductionist?

Listen, in the early 20th century, we didn’t know a lot about internal medicine. Now 100 years later, we have a much more reductive and straightforward understanding and framework for thinking about the causes and the conditions of organ problems or skin problems or some other system. We don’t have that in psychiatry. To pretend that we do is a massive disservice to the profession and will do nothing.

In my clinical practice, I try to be humble in the sense that I say this is our best guess. We have some data about symptoms that hang together and what generally works. But, right now in 2017, there’s a lot we don’t know; so we just have to try. We just have to see what would be helpful now. That process will lead us toward a better understanding.

I wish I could do a brain scan. There are people who do that. There are people who charge big money to put someone in a brain scanner and then give them their own special proprietary psychiatric diagnosis. I can see why that would be very persuasive to some people that are struggling. Imagine a family member that you brought to five different medical professionals and you can’t get help. So the idea that someone can just scan your brain and give you a diagnosis and get at the root cause of the problem seems like a godsend. But, it’s just not where we are today. We shouldn’t pretend. We should just try to address the problem as it presents itself today and see where it leads us.

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Behavioral genetics is a huge area of ethical investigations. One of my mentors up at Columbia University has an NIH Center grant to explore this very question. How do ideas about behavioral genetics trickle down into society, especially into law—but also into the general public. One of the many dangers or assumptions is the idea of determinism, that because we can explain your genetics we can give you a sense of what your risk of heroin addiction is, for example, which some of these tests were spitting out at one point. We’ve since had to scale it back, appropriately.

It’s being used in courts too. The idea that different neurotransmitter gene variants might lead to risks of violence has been used both to mitigate and to aggravate sentences. If someone has a gene that predisposes them toward violence or aggression, in one conception, they’re suffering from something out of their hands, and they deserve special consideration. We should go easy on them.

But the alternative view—and a more utilitarian view—is they’re higher risk! It might not be their fault, but they’re a higher risk for future violence and so we should detain them and keep them away from the population. We need to work through how we make sense of some of those behavioral findings in genetics, without getting overly deterministic or overpromising on what we can actually deliver about understanding human psychology.

How is the use of the “addiction” label changing inside psychiatry?

For years now, for several iterations of the Diagnostic and Statistical Manual, the official manual of psychiatric diagnoses, there’s been no mention of addiction. We’ve thrown out the idea of addiction. We talk more specifically about substance-use disorders. It used to be substance dependence versus substance abuse. There was a recognition that the idea of addiction had a lot of cultural baggage, a lot of assumptions about what it meant. Different communities, different people struggling with it had different ideas about what it meant, so we just threw it out.

But, it still has a lot of cultural traction and people still use it. My board certification is addiction medicine, so someone in medicine thinks it’s useful to use that label. I don’t think that psychiatry, just by writing some official diagnostic manual will get people to stop using the word addiction. It still has some cultural relevance; it still has traction. People still talk about themselves as if they have addictions. I think even just in practice, that can be a useful idea to interrogate. Do you think you’re addicted or not? Why? What does it mean to you? What does it matter to you whether or not you have that label?

How did you get started in science?

It was a teacher! Yeah, it was Mary Jane Roethlin, in Glen Ridge High School, and she taught a great biology class. One of the things she told us to do was to read the Science Times every week, and we got extra credit if we could come in and prove to her that we had actually read some article somewhere. I realized I really liked reading about science. It was science journalism, specifically; I mean, it was her, it was primarily the teacher because of the conversations and the way she engaged with us, but she relied very strongly on science journalism, not just in that context, but across other contexts, as a way of translating it to students. Textbooks are all well and good, but for most students, they’re relatively boring—but if you can tell a story, if you can give it some life, then it can be motivating. So I have her to thank.

The University of North Carolina at Chapel Hill has a very good, small, conservatory-like music program within the huge university, and I got sucked in. And so I doubled majored, and music predominated. It was mostly voice lessons, and recitals, and operas, and then I squeezed in the biology on the side.

My real education in biology was working in a lab in my freshman year. I just went around from lab to lab, looking for a job, and eventually worked my way in washing dishes. Over time, over the four years, I got to meet some of the master’s students and see what they were like and what they were interested in, and how they were engaging with science. It was through conversations with them that I realized I wanted to be a physician scientist, and not be solely within just research biology—not that there’s anything wrong with it, but I wanted an element of direct service too that they were describing missing.

How did you get interested in addiction?

I’ve had a few different threads running through my training. I’ve been interested in neuroscience; interested in ethics; and it didn’t seem like there was a way to combine them all. The fact of the matter is, in academic medicine, you eventually have to choose some sort of direction or some sort of program. Addiction is the most complex and philosophically challenging mental disorder—for me—I’m not saying it’s any better or worse, or that there’s anything special or that it deserves more credit. But, to me, some of the questions that people struggle with in the consulting room seem deeply ethical and philosophical.

For example, someone might have done something awful—a DUI and injured someone, or caused a lot of interpersonal damage. How do you make sense of that if it was largely the outgrowth of a substance abuse disorder? Do you say you’re not responsible at all? Do you say, “I’m fully responsible for it, and yet I still have this disorder”? People struggle with that and that struggle matters to the way they conduct their lives and the way that they deal with the disorder.

Likewise, the fundamental problem, which I bring up in my Nautilus article this month, of how do you extend your will over time? When someone is depressed, they generally appear depressed. They feel depressed. They act depressed in that moment. That’s true for many other mental disorders, but addiction is—not the only one—but one of the most striking examples in psychiatry of someone who seems to be at war with themselves. They say one thing in one moment and then, because of competing motivations or other forms of suffering or just chance of being exposed to temptation or cravings, will act completely contrary to their stated interests. That dissociation between their stated intentions and their actual behaviors is part of the reason this becomes so heavily moralized.

Without a good understanding of the psychological process that drives that sort of behavior, people simply say this person is a liar, or they’re dishonest, or they’re immoral. Thankfully, I think that’s a minority view now and people are coming around to a different understanding of addiction and moral responsibility. But, it’s still a struggle. It still upsets our folk psychology of how a person acts. It’s an extreme example of that problem of extending your will over time, bringing your actions in line with your ultimate goals. I think it’s interesting in that sense and people suffer.

I would just say that psychiatry is significantly underserved. We don’t have enough psychiatrists in this country, and we certainly don’t have enough addiction providers, and we don’t have enough people who are thinking in a rigorous or even compassionate way about addiction. It seems to me a great way to marry a real public service where there’s a tremendous amount of need with some really confusing questions about human nature.

Who are some of your professional heroes?

Within psychiatry, some of my heroes are the people who take that broader conception of the place of psychiatry in society. Some of these folks are skeptics, people who question the role of psychiatry, the way we think about psychiatry right now.

One very specific and focused critic right now is Allen Frances, who I love. He’s a brash and outspoken former chair of a major psychiatry department, who speaks out vigorously against the idea of psychiatric diagnosis the way it’s come about right now. He played a role in establishing some of the earlier diagnostic manuals and now says our current one is total crap and it should be totally thrown out or at least it’s been an unmanageable expansion. I don’t agree with all his views, but I think that there’s a tendency in academic medicine, like all of academia, to get behind a common cause and advocate for your profession or for your own interest. There have been moments in history where psychiatry has not been skeptical enough, and as a result, has lost sight of some of it’s shortcomings or issues.

But then there are also people who are deeply interested in the world of psychiatry and society on a more value-based or philosophical level, so Robert Jay Lifton is one, who wrote about atomic bomb victims, but also the famous book, The Nazi Doctors. It looks at the writing of books about psychiatry and society as form of activism or advocacy. It’s not necessarily working for an immediate goal, but raising consciousness in a broader sense.

Another is Irving Allen, who worked within a Freudian model and thought of himself as a psychoanalyst, but thought that Freud didn’t care adequately about death. So, he did a lot of work to raise the profile of existential psychiatry. There have been many other variants on that, but just the idea of a completely missed dimension of a human life. As a Zen practitioner, I think it’s useful to think about death. In some retreats, they beat a drum and say, “May I respectfully remind you that life is short. You’re going to die.” Essentially; I’m paraphrasing. I agree that we have a tendency of missing that dimension of life and focusing on some other weighty concepts that are distracting enough that they take us away from that question.

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